instances are given, but none of the subjects developed nausea. About 58 operations have been performed under this type of anesthesia without loss of consciousness. An anesthesia or analgesia that may be extended to a duration of several hours with this sort of ethylene-charged ether. An ether that may be employed for a painful change of dressings, where anesthesia would scarcely be thought of, or for the wounds of industry or of war or for painful labor.

Ordinary U. S. P. ether is but a carrier of other substances. Some foreign substances are necessary, but some are detrimental in the condition known as surgical anesthesia. This ethylene-charged fluid may be used as is the ordinary ether, but it is free from after effects and recovery is so quick that patients have returned to full consciousness before they could be sewed up. It is well to bear this in mind and not to order the discontinuance of the anesthetic until the wound dressing is completed. The anesthesia or analgesia do not appear to retard the processes of labor. Pain may be relieved without obtaining unconscious states. The grade of influence from the lightest primary to the profoundest secondary would appear to be under the control of the administrator.

Soap and Water vs. Antiseptics.

Captain J. B. Haycraft, M.B., R.A.M.C., in British Medical Journal, comes out strongly for soap and water for wound cleansing. Pure hard soap is cut into shavings and dissolved in twenty parts hot water that has been boiled. When required for use the solution is mixed with an equal volume of sterile water. He reaches the following:

Conclusions.

1. Soap solution easily permeates and comes into contact with the whole surface of the wound. It acts as a mechanical cleansing agent, washing away all débris.

2. Complete excision of a wound leaving an aseptic surface is possible only in superficial wounds and in superficial muscular wounds. It is impracticable in deep penetrating wounds, compound fractures, etc., on anatomical grounds, and it would also entail a much freer removal of tissue, which may impair future functional result. These latter cases, when treated by soap solution and primary suture, heal better than if an antiseptic such as eusol or bipp had been used. It follows from this that the tissues themselves are able to deal successfully with any infection which is left behind without the aid of any antiseptic. This point is particularly exemplified by those cases in which there is at first an intense local reaction following on the operation; it subsides as the tissues gain the upper hand.

3. Success depends on getting cases within a few

hours of being wounded, before infective processes have spread far into the adjacent muscles, on the thorough removal of dead or grossly damaged tissues, and on the localization by x-rays and removal of any foreign body that may be present.

4. Compound fractures of the upper extremity practically always do well; only three cases of fracture of the femur have been thus treated, and of these two were successful, but the number is too small to warrant a definite opinion. It is necessarily the most severe type of case one has to deal with, but the results of those cases have been distinctly encouraging.

5. The advantages of primary suture are obvious: (a) Easy, rapid, and painless dressings; (b) time is saved for everybody once the patient has left the operating theatre; (c) it is economical. The time taken in the operating theatre is, however, considerably longer, and this generally forbids the use of the method when the pressure of work is high. 6. One of the most important points is that no severe injury which has been stitched up should be evacuated for at least a week-first, because movement may just turn the balance during the early days of local reaction when the tissues are getting the upper hand and cause failure, and, secondly, because when it is very difficult to decide whether the case should be opened up or not the operator himself is in a much better position to judge what is likely to be taking place inside the wound he has sewn up than someone else who gets the case later; consequently stitches remain in which may otherwise be taken out perhaps through no fault of any

one.

7. No opinion can be given as to the ultimate functional result as to bony union and action of muscles.

In those cases in which primary suture has been out of the question owing to gross loss of tissue, after the usual operative procedure I have used a soap pack after the manner of the salt pack. It has been left in as a rule for five to seven days, and when taken out left a beautifully healthy wound.

Preparation of Catgut.

A certain well-known surgeon has just picked up some catgut and his enthusiasm over this specimen is so unbounded as to be embarrassing. Here is the old, old process which may date from Sir Astley Cooper for all Scissors knows. Wrap around one-ounce ointment jar with four turns of a gauze bandage. Wind some No. 1 or No. 0 catgut upon that gauze. Cover with four additional turns of gauze bandage and tie securely with thread. Immerse in equal parts grain alcohol and tincture of iodine for one week. Remove therefrom and immerse immediately and undisturbed in iodin crys

tals one part, amyl alcohol twenty parts, for another week. Remove, lay on a plate, let dry and examine.

After the catgut has been in the grain alcohol mixture for one week it is all swelled up; it stretches and its strength is greatly decreased. Pulling on it will merely ruin it or break it; but the swelling and softening show penetration by the antiseptic. The second week in the amylic mixture makes for that very desirable hardness and strength.

Auto Sensitized Foreign Protein: Its Superiority as a Subcutaneous or as an Intravenous Injection. Wm. Lee Secor, A.M., M.D., F.A.C.S., Kerrville-on-the-Guadalupe, Texas, in Med. Record.Injection of a foreign protein is becoming a popular therapeutic procedure. This paper is to acquaint such as may be interested that during an experience of four years blister serum had all the advantages with none of the disadvantages of serum that had been obtained from defibrinated blood.

1. It is as potent as any other foreign protein and more potent in pellagra.

2. It produces little or no reaction.

3. It is easily obtained.

4. Hundreds of injections have given no harmful result nor even a local abscess.

5. Its technique is so simple that any physician may obtain it and may employ it.

To obtain this serum, wash a small area of the patient's chest with alcohol; place upon it an oilsmeared piece of cantharides plaster (12 x 11⁄2 inches), cover all with a perforated aluminum eyeshield and hold this in place with adhesive strips.

Place such a plaster in the evening and by the next morning from one to three ccs. of serum will be formed, though with several patients fortyeight hours were necessary to produce one cc. af

serum.

If the shield is removed, an upper corner of the plaster is raised and if the serum is withdrawn with a sterile hypo. syringe, then any requisite amount may be immediately injected into a vein or into the subcutaneous tissues of the arm.

The plaster is carefully removed and the skin area is dressed with sterile gauze smeared with sterile petrolatum. There need be no pain, or at most a very slight discomfort, therefore no patient as yet has objected to repeated treatments.

Pellagrins will get well by the administration of auto-serum alone; but progress is rapid if arsenic and a generous diet are given at the same time.

Comment.

Those of us who were brought up upon blisters, as it were, will recall that the blister plaster had stamped upon it the words "oil the face of the

plaster before applying." This we were very careful to disobey. Many amusing tales of the uncertainty of oiled plaster might be told, and of its being applied to one area, sliding down to an area where it was not at all desired and there sticking fast. Do not oil the plaster but heat it gently before applying and notice the exactness of the procedure, time and amount of serum.

Fundal Hysterectomy to Reduce Menstruating
Surface.

Gordon K. Dickinson, M.D., F.A.C.S., Jersey City, N. J. Transactions A. Assoc. Obs. and Gyns., Sept., 1917.-The method proposed is a fundus resection per vaginam. The anus is purse-stringed to prevent fecal contamination, each labium is retracted and an ounce or more of half-strength iodine tincture is poured into the vagina. The usual volsellum pulls down the cervix, through a transverse incision the bladder and cervix are separated and then the fundus is easily rotated into the vagina. After careful inspection, clips are applied alongside of the uterus to compress blood-vessels and to act as retractors. A suitable V-shaped section is removed and both fornices are cauterized, together with touching up the cervical portion. The two flaps are approximated, staunching hemorrhage. The peritoneal surface is brought together by an additional running suture of catgut, clips are removed, the uterus is replaced and the anterior colpotomy wound sutured.

Comment.

This would appear to be a great improvement over former methods. Perhaps it may be interesting to quote a case history of more than thirty years ago and then to contrast the two methods. In his book on "Pelvic Surgery," R. Stansbury Sutton states the following (abstract of page 15): "Operation February 2, 1884. A silk ligature was passed through the supra-vaginal cervix from before backwards. One half of the ligature embraced one half the cervix and corresponding uterine artery, the other half ligature, the opposite half and artery. The fundus was cut, leaving a wedge-shaped opening in the stump which was closed with silk-woven gut sutures. Uneventful recovery."

Dr. Dickinson does not open the abdomen through the front or muscular wall. Dr. Sutton left the circulation permanently interfered with by ligation, whereas the clips, when removed, allow the circulation some chance to re-establish itself. Dr. Dickinson's cases should recover quickly, while healing is certainly slowed or prevented by the hemostasis of the ligature, though the interference with healing and nutrition really was not so great nor so common as might be thought from the premises.

Garrigues had a couple of cases that Scissors

knows about and those two really did very well eventually, after a hospital residence of six weeks, which is possibly double the time that elapses with the new mode.

Thermo-Therapy in Gonorrhea.

Burton Peter Thom, M.D., New York, in N. Y. Medical Journal. It was the custom among soldiers suffering with acute gonorrhea to place the penis between two heated roof tiles for as long a time as the heat could be borne. This mode of treatment in Eastern Europe sixty years ago resulted in inflammation, pain and swelling, but the purulent discharge ceased promptly and the disease apparently was cured in a few days.

It has long been known that pyrexia will cause cessation of a gonorrheal discharge. In typhoid and pneumonia this has been often noted, nor can an individual with high fever be inoculated with gonorrhea.

The ideal treatment would seem to be a combination of local and systemic heat increase. To destroy organisms in situ and to produce changes in blood that will antagonize the circulating toxins.

Hot permanganate irrigations, massive doses of santalyl salicylate and the ordinary Turkish bath are recommended; the patient is directed to take such a bath several times a week, to remain in the hot room as long as possible and to abstain from cooling off afterward.

Comment.

Scissors asked the proprietor of a Turkish bath about sending gonorrheal cases to his establishment. Try it; make a test case of it, and after your recovery let us know how you come out in the courts and with the Health Department. Or, rather, don't do it; for at least that one proprietor expressed opinions that might be termed both indignant and truculent. He appeared to assert that the Doctor would be damaged physically, sanitarily and legally in about that order and that each damage might be considered punitive. He may be wrong, of course; but he and some of his patrons did not think so. Therefore, perhaps, it might be just as well to find out the opinion of any proprietor in advance, lest a great deal of unnecessary trouble should arise in consequence of sending a contagious disease into a resort like a Turkish bath. The value of the bath is not here in question; the rights of its manager and patrons are.

Sphagnum and Sawdust.

This will answer several inquiries. Sphagnum and other mosses have been used as wound dressings for ages. In Scissor's student days sphagnum was put out of the running by the advantages and enormous supply of sawdust. A look or glance at any large saw-mill will reveal that a carload of

sawdust may be obtained with rather less time expenditure than a bushel of sphagnum or any other moss. Sawdust may be baked or rendered antiseptic or made into fine wood-flour or packed in gauze bandages a la pin-cushion style. It is very absorbent, as it is, after thoroughly drying, or it may be baked into charcoal. When a wound is washed or irrigated sawdust particles simply float away.

Audain and Masmonteil, in Presse Médicale. Massive intravenous sugar injections in isotonic solution very quickly induce leucocytosis; and the procedure has proven markedly beneficial in the treatment of septicemia. Glucose solution is isotonic at 47.6 parts in 1,000; and 300 to 500 grams of solution are injected, and even up to 2,000 grams a day in divided doses. This may be continued for several days or until the temperature is normal.

A. C. Croftan, in Jour. A. M. A. The routine practice of starvation in rendering a diabetic sugarfree is often harmful, especially in moderate cases, a restricted diet sufficing. The appearance of edema in the starvation treatment is always a sign of danger, for it shows that the patient is living on his own tissues. The rectal administration of pancreatized oatmeal with alcohol and glycerine and the giving of alkalies, tend to prevent edema during starvation.

Practical Therapeutics

New Light on Opium

David L. Macht, in the December number of the American Journal of the Medical Sciences, treats of the action of opium and some of its alkaloids on the digestive tract. Opium and morphine are used by most physicians promiscuously and interchangeably in the many conditions in which an opiate is indicated. Perhaps the only difference between the two recognized by the average practitioner is that morphin can be administered by hypodermic injection while opium must be given by mouth. With the appearance on the market of soluble preparations of total opium alkaloids, such as pantopon or pontopium, even "opium" can be given now by injection, and this difference therefore now disappears. A great many men therefore regard morphin as simply a more concentrated form of opium. Recent investigations, however, on the pharmacological action of various opium alkaloids have revealed that the so-called "minor" alkaloids of opium play a very important pharmacologic and therapeutic role, and render the properties of opium as such or of combinations of its various alkaloids radically different from those of its principal alkaloid, morphin, when given alone. Macht has shown that the effect of opium and of various combinations

of its alkaloids on the respiration is in important respects very different from that of morphin. He has also shown that the analgesic properties of morphin and opium are quite different, and he has recently called attention to the difference between opium and morphin in their effect on the ureter in kidney colic. The action of opiates on the alimentary canal is one of the cardinal therapeutic indications for their administration. Nausea and vomiting are among the commonest sequela which the physician encounters after administration of opium, especially after morphin. These untoward symptoms which may occur after very small doses of morphin, although not dangerous in themselves, are disagreeable enough to be largely responsible for the employment of other opiates instead, either in the form of individual alkaloids, such as codein or dionin, or of various combinations. The vomiting produced by morphin has been conclusively shown to be of central origin, that is, to be produced by stimulation of the vomiting centre in the medulla. His practical deductions are in the first place that morphin alone is more nauseating than when given in combination with other opium alkaloids, and in the second place, that even minute doses of morphin, doses which are insufficient for the relief of pain, may nevertheless produce nausea. It is therefore not logical to decrease the dose of morphin for the purpose of eliminating its nauseating effect.

The absorption from the stomach, insofar as it takes place, does not seem to be interfered with by these drugs. The secretions of the stomach, however, are markedly increased. A very interesting point is the excretion of morphin by the stomach wall. The drug after having been absorbed from the intestines is re-excreted by the gastric mucosa. This is of practical importance and suggests lavage as a rational procedure in all cases of opium or other morphin poisoning. Perhaps the most striking effect of morphin on the stomach is the pylorospasm following its administration. Morphin causes a powerful contraction of the pylorus which lasts for many hours. This pylorospasm is regarded by Magnus as one of the principal factors in tending to produce constipation after morphin. Opium or the total opium alkaloids, does not produce such a powerful spasm of the pylorus.-As abstracted in Cleveland Medical Journal.

Sodium Bicarbonate in Ether Anesthesia. George B. Wood, M.D., Philadelphia, in The Virginia Med. Semi-Monthly.-This is taken from the proceedings of the American Laryngological Association, as reported by Emil Mayer, M.D., of New York: Modern investigation has shown that both ether and chloroform anesthesia, after a duration of thirty minutes, lower the alkali reserve of the blood. This reserve may be increased by the administration of sodium bicarbonate. Therefore

this administration should become a routine preoperative measure as a prophylactic against postoperative vomiting. Robert C. Lynch, M.D., of New Orleans, stated during the discussion that five grains of citrate of soda were more agreeable to many patients than a quarter teaspoonful of bicarbonate; though either should be begun three or four days prior to anesthesia and should be administered t. i. d. This may be followed by a post-anesthetic half-pint 5 per cent. solution of glucose given by the "drip" rectal method. The post-operative use of codein and morphin will increase acetone in urine and cause a cyclic vomiting. During the spring and summer months more cases of acidosis occur than during winter, therefore a patient submitted to general anesthesia in warm weather should invariably receive both a preliminary soda treatment and a post-operative Murphy drip with the 5 per cent. glucose solution.

Dr. Wood, in closing, remarked that the dosage of bicarbonate should be one and a half grains for each year of age and the last dose should be given an hour or two before operation.

After operation, a solution of the soda may be given by enema, if constant vomiting or other evidence of acidosis be present. The restriction of food, ante-operation, should be only sufficient to assure an empty stomach when the ether is given. One case, that had been practically starved by the family physician, was the most severe case of postanesthesia acidosis that the speaker had seen.

Comment.

Perhaps it may be well for Scissors to point out that many physicians are firm believers in Haig's Rule: "A low diet is equivalent to a dose of alkali." That depends a good deal upon what the previous diet has been, for it is very easy to put a horse or a cow upon a starvation diet and by this means to turn muddy, turbid, alkaline urine of the full-fed state into clear, sherry-colored acid urine. For a time at least there is small difference between an animal feeding upon the tissues of another animal, or the so-called meat diet, and that animal feeding upon its own tissues by fasting. Either meat or fasting may produce acidosis; that production depends upon many circumstances.

Anorectal Varices in Pregnancy

Suarez, in Revista de Medicina y Cirugia Practicas, values the use of olive oil in prophylaxis. The toilet of the rectum and anus is of especial importance, making free use of boric acid solution, often applied hot. The following ointment is found efficacious: Zinc oxide, 2 parts; epinephrine solution (1 in 1,000), 1 part; orthoform, 1 part; stovaine, 1 part; petrolatum, 30 parts. More or less minor surgery may be needed in some cases.